Some practices in the Morecambe Bay area will be implementing “core teams” of healthcare workers to look after small patient populations to free up GP time, the clinical chair of Cumbria Clincial Commissioning Group (CCG) has said.

Dr Hugh Reeve, who is also a GP in the area, said that next year the integrated primary and acute care system, Bay Health and Care Partners, will look into implementing teams that include a GP, nurse, health care assistant and admin staff to look after 2,500 patients.

Reeve told delegates at the King’s Fund’s Integrated Care Summit yesterday that the core team, which is based on a model already in place in parts of America, would look after immunisations and chronic diseases, among other things.

He told The Commissioning Review that patients will only be registered with their GP “in name” and will instead be given a card with the name of their GP on it, along with the names of a nurse, a health care assistant and an admin contact.

Evidence from the American system, Reeve said, shows the scheme will allow GPs to only see 12 people with “complex, difficult problems” each day and spend half an hour with them if they need to.

“To me that’s a nirvana,” said Reeve, who added that he is having “increasingly less time” after one partner left and another went on maternity leave, leaving him and two new doctors to manage their ageing patient population.

He said: “I think we’ve not done enough of this. We’ve done a lot of work around how we bring practices together and join up back office stuff but it hasn’t addressed the clinical model in which we work.

“And I think there’s the opportunity there to really look at which professional it is that patients see and then we can be much better at directing them and handing people over in a way that doesn’t feel people are being shunted around.”

He stressed the importance of ensuring “that some of the investment that sits in STPs (sustainability and transformation plans) gets invested in supporting that sort of level of change”, otherwise “nothing else will change”.

The plan also involves a wider team of clinicians, dieticians, physiotherapists and social care, which will “wrap” around four of these core teams, supporting 10,000 patients.

Groups of these 10,000 patients would then form an integrated care community, supported by a district hospital and service around 30,000 patients, said Reeve.

Bay Health and Care Partners currently serves 365,000 people and includes 47 practices, two CCGs, four NHS trusts, two county councils and an ambulance service.